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3.2.4 Personal Supervision Versus Direct Supervision
Physician services include reasonable and medically necessary services ordered and performed by a physician or under the personal supervision of a physician that are within the scope of practice of their profession, as defined by state law. The physician must examine the client, make a diagnosis, establish a plan of care, and document these tasks on the appropriate client medical records before submitting claims. If such documentation is not present in the appropriate medical record, then any payment may be recouped. The services are benefits if provided in the office, client's home, hospital, or elsewhere.
To be payable by the CSHCN Services Program, the services must be personally performed by the physician or by a qualified person working under the personal supervision of the physician. Personal supervision means that the physician must be in the building of the office or facility when and where the service is provided. Direct supervision means the physician must be physically present in the room at the time the service is provided. In instances where one physician is taking a call for another physician, the performing physician must bill the services provided.
TMHP may make payments to a physician for CSHCN Services Program-covered services provided by another physician acting as a substitute. Such substitution arrangement may be either informal reciprocal arrangement of 14 days or fewer, or long-term arrangement (up to 90 days) involving per diem or fee-for-time compensation.
The substituting physician is not required to enroll with the CSHCN Services Program. The name, address, and CSHCN Services Program provider identifier of the billing provider must be entered in Block 33 of the CMS-1500 claim form. When a physician in a group practice bills for substitute physician services, the physician's provider identifier (not the substitute physician's) must be indicated in Block 24J of the claim form. The name and address of the substituting physician must be documented on the claim form in Block 19.
If billing for a substitute physician, the modifier Q5 or Q6 must follow the procedure code in Block 24D for services provided by the substituting physician.
If the attending physician provides personal and identifiable direction to interns or residents who are participating in the care of a CSHCN Services Program client in a teaching setting as an approved and accredited training program by the appropriate accreditation agencies, the physician's services are a benefit. For major surgical procedures and other complex and dangerous procedures or situations, the attending physician must be physically present during the procedure or situation to provide personal and identifiable direction. If personal and identifiable direction is not provided or is not appropriately documented, any payment for services may be recouped.
The attending physician must demonstrate that personal and identifiable direction was provided within the following criteria:
• Reviewing the client's history and physical examination and personally examining the client within a reasonable period after the client's admission and before the client's discharge.
•Confirming or revising the client's diagnosis.
•Determining the course of treatment to be followed.
•Ensuring that any supervision required by the interns or residents is provided.
•Entering in the client's medical record appropriate daily documentation of the tasks identified above, before submitting the claim.
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